ImportanceThe prevalence of robotic-assisted anterior abdominal wall (ventral) hernia repair has increased dramatically in recent years, despite conflicting evidence of patient benefit. Whether long-term hernia recurrence rates following robotic-assisted repairs are lower than rates following more established laparoscopic or open approaches remains unclear.ObjectiveTo evaluate the association between robotic-assisted, laparoscopic, and open approaches to ventral hernia repair and long-term operative hernia recurrence.Design, Setting, and ParticipantsSecondary retrospective cohort analysis using Medicare claims data examining adults 18 years and older who underwent elective inpatient ventral, incisional, or umbilical hernia repair from January 1, 2010, to December 31, 2020. Data analysis was performed from January 2023 through March 2024.ExposureOperative approach to ventral hernia repair, which included robotic-assisted, laparoscopic, and open approaches.Main Outcomes and MeasuresThe primary outcome was operative hernia recurrence for up to 10 years after initial hernia repair. To help account for potential bias from unmeasured patient factors (eg, hernia size), an instrumental variable analysis was performed using regional variation in the adoption of robotic-assisted hernia repair over time as the instrument. Cox proportional hazards modeling was used to estimate the risk-adjusted cumulative incidence of operative recurrence up to 10 years after the initial procedure, controlling for factors such as patient age, sex, race and ethnicity, comorbidities, and hernia subtype (ventral/incisional or umbilical).ResultsA total of 161 415 patients were included in the study; mean (SD) patient age was 69 (10.8) years and 67 592 patients (41.9%) were male. From 2010 to 2020, the proportion of robotic-assisted procedures increased from 2.1% (415 of 20 184) to 21.9% (1737 of 7945), while the proportion of laparoscopic procedures decreased from 23.8% (4799 of 20 184) to 11.9% (946 of 7945) and of open procedures decreased from 74.2% (14 970 of 20 184) to 66.2% (5262 of 7945). Patients undergoing robotic-assisted hernia repair had a higher 10-year risk-adjusted cumulative incidence of operative recurrence (13.43%; 95% CI, 13.36%-13.50%) compared with both laparoscopic (12.33%; 95% CI, 12.30%-12.37%; HR, 0.78; 95% CI, 0.62-0.94) and open (12.74%; 95% CI, 12.71%-12.78%; HR, 0.81; 95% CI, 0.64-0.97) approaches. These trends were directionally consistent regardless of surgeon procedure volume.Conclusions and RelevanceThis study found that the rate of long-term operative recurrence was higher for patients undergoing robotic-assisted ventral hernia repair compared with laparoscopic and open approaches. This suggests that narrowing clinical applications and evaluating the specific advantages and disadvantages of each approach may improve patient outcomes following ventral hernia repairs.

中文翻译：

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腹疝修补术后的手术方法和长期复发


重要性 近年来，机器人辅助前腹壁（腹侧）疝修补术的普及率急剧上升，尽管患者获益的证据相互矛盾。机器人辅助修复后的长期疝复发率是否低于更成熟的腹腔镜或开放手术的复发率仍不清楚。 目的评估机器人辅助、腹腔镜和开放手术腹疝修复与长期手术疝之间的关联设计、设置和参与者使用 Medicare 索赔数据对 2010 年 1 月 1 日至 2020 年 12 月 31 日期间接受选择性住院腹疝、切口疝或脐疝修补术的 18 岁及以上成年人进行二次回顾性队列分析。数据分析于2023 年 1 月至 2024 年 3 月。暴露腹侧疝修补术的手术方法，包括机器人辅助、腹腔镜和开放手术。主要结果和措施主要结果是初次疝气修复后长达 10 年的手术疝复发。为了帮助解释未测量的患者因素（例如疝气大小）的潜在偏差，利用机器人辅助疝气修复术作为仪器随时间推移的区域变化进行了仪器变量分析。 Cox比例风险模型用于估计初始手术后长达10年的风险调整累积手术复发率，控制患者年龄、性别、种族和民族、合并症和疝气亚型（腹侧/切口或疝）等因素。结果 共有 161 415 名患者纳入研究；患者平均年龄 (SD) 为 69 (10.8) 岁，其中 67 592 名患者 (41.9%) 为男性。 2010年至2020年，机器人辅助手术的比例从2.1%（20 184例中的415例）增加到21.9%（7945例中的1737例），而腹腔镜手术的比例从23.8%（20 184例中的4799例）下降到11.9% （7945 例中的 946 例）和开放程序从 74.2%（20 184 例中的 14 970 例）下降到 66.2%（7945 例中的 5262 例）。与腹腔镜手术（12.33%；95% CI，12.30%-）相比，接受机器人辅助疝修补术的患者的 10 年风险调整累积手术复发率较高（13.43%；95% CI，13.36%-13.50%）。 12.37%；HR，0.78；95% CI，0.62-0.94）和开放（12.74%；95% CI，12.71%-12.78%；HR，0.81；95% CI，0.64-0.97）方法。无论外科医生手术量如何，这些趋势在方向上都是一致的。结论和相关性本研究发现，与腹腔镜和开放手术相比，接受机器人辅助腹疝修复术的患者的长期手术复发率更高。这表明缩小临床应用范围并评估每种方法的具体优缺点可能会改善腹疝修复后的患者预后。